Resuscitation Fluid

ABSTRACT

The present invention relates to a resuscitation fluid which includes an ionic salt at a concentration above about 0.9%, at least one soluble protein, at least one intermediate energy substrate, and optionally an agent to mitigate intracellular acidosis. Methods of making and using the fluid are also described.

BACKGROUND OF THE INVENTION

The present invention relates generally to the treatment and preventionof hemorrhagic and ischemia disorders. More specifically, the presentinvention relates to a method and composition for treating andpreventing one or more of hemorrhagic shock, septic shock, hypotension,acidosis, and/or hypovolumia.

Shock is a serious medical condition where the rate of tissue perfusionis insufficient to meet demand for oxygen and nutrients. Thishypoperfusion state is a life-threatening medical emergency and one ofthe leading causes of death for critically ill people. Shock may alsolead to many other medical emergencies, such as hypoxia and/or cardiacarrest.

The management of shock requires immediate intervention. Re-establishingperfusion to the organs is the primary goal and is achieved by restoringand maintaining the blood circulating volume, ensuring oxygenation andblood pressure are adequate, achieving and maintaining effective cardiacfunction, and preventing complications.

The prognosis of shock depends on the underlying cause and the natureand extent of concurrent problems. Hypovolemic, anaphylactic, andneurogenic shock are readily treatable and respond well to medicaltherapy. Septic shock, however, is a grave condition with a mortalityrate between 30% and 50%. The prognosis of cardiogenic shock is evenworse.

Shock is said to evolve from reversible to irreversible in experimentalhemorrhagic shock involving certain animal species (dogs, rats, mice)that develop intense vasoconstriction of the gut. Death is due tohemorrhagic necrosis of the intestinal lining when shed blood isreinfused. In pigs and humans, this is not seen and cessation ofbleeding and restoration of blood volume is usually very effective.Prolonged hypovolemia and hypotension does, however, carry a risk ofrespiratory and then cardiac arrest. Insufficient perfusion of the brainmay be the greatest danger during shock. Urgent treatment is essentialfor a good prognosis in hypovolemic shock.

Shock, at its most fundamental, can be considered a warm ischemia. Warmischemia is an absolute or relative shortage of the blood supply to anorgan or tissues. Ischemia can also be described as an inadequate flowof blood to a part of the body, caused by constriction or blockage ofthe blood vessels supplying it. Since oxygen is mainly bound tohemoglobin in red blood cells, insufficient blood supply causes tissueto become hypoxic, or, if no oxygen is supplied at all, anoxic. This cancause necrosis (i.e., cell death). Necrosis due to ischemia usuallytakes about 3-4 hours.

Tissues that are especially sensitive to inadequate blood supply includethe heart, the kidneys, and the brain. Ischemia in brain tissue, forexample due to stroke or head injury, causes a process called theischemic cascade to be unleashed, in which proteolytic enzymes, reactiveoxygen species, and other chemicals that are harmful in this context candamage and may ultimately kill brain tissue. Restoration of blood flowafter a period of ischemia can actually be more damaging than theischemia. Reintroduction of oxygen causes a greater production ofdamaging free radicals, resulting in reperfusion injury. Withreperfusion injury, necrosis can be greatly accelerated.

The present standard of care in the initial management of shock includesrapid administration of large volumes of isotonic crystalloid solution,which can be up to several liters in an adult patient. In situationswhere fluid addition to the vascular system is required, such as forresuscitation, the practice has been to add isotonic fluids insufficient quantity to replenish vascular fluid volume. In practice,this has often been at a rate of 1:1 as compared to blood loss, andoften as high as 3:1 compared to blood loss due to physiologicequilibration of resuscitative fluid between the intravascular andinterstitial space. Advantages of this practice were avoidance orreduction in triggering anti-inflammatory response, the provision ofoxygen to the cells, and the replenishment of osmotic pressure in thevascular system. On the other hand, large volumes of fluids are requiredto be administered, and cell death often occurs despite the additions oflarge volumes of the fluids due to cells lapsing into a regime ofanaerobic metabolism from which they could not recover.

A preferred fluid is Ringer's lactate, although normal saline or othersimilar isotonic crystalloid solutions are also used. Recommendedcontinued treatment is based on the observed response to the initialfluid therapy. American College of Surgeons, 154, 585-588, (1987). As ageneral rule, guidelines are based on the “three for one” rule. This isbased on the long-standing empirical observation that most hemorrhagicshock patients require up to 300 mL of electrolyte solution for each 100mL of blood lost.

Other isotonic fluid replacement solutions have been used, includingisotonic crystalloid solutions mixed with macromolecular solutions ofplasma proteins or synthesized molecules with similar oncotic properties(colloids); including albumin, dextran, hetastarch or polygelatin in0.9% NaCl. Whole blood is also used, but it is expensive, oftenunavailable and cross matching may delay therapy.

Crystalloids and colloids have been used as volume expanders, butgenerally must be infused in large volume. Such large volumes may causeperipheral and pulmonary edema. Additionally, the large volumerequirements of isotonic fluids means that there are time delays andlogistic difficulties associated with vascular delivery of effectivetherapy.

Hyperosmotic crystalloid and hyperosmotic/hyperoncotic(crystalloid/colloid) formulations have been reported to offer somephysiological benefits for the treatment of circulatory shock, includingimproved efficacy for restoration of overall cardiovascular function inanimals and man compared to conventional resuscitation. U.S. Pat. No.3,993,750. Normalization of circulatory function has been obtained withsuch solutions. U.S. Pat. No. 4,927,806. Small volumes ofsalt/concentrated dextran formulations have been shown to rapidlyrestore and sustain normalization of circulatory function in hemorrhage.Surgery 100, 239-246 (1986) and U.S. Pat. No. 4,908,350. However, thereremain some important limitations/side effects.

Hypertonic saline infusions in shocked animals and patients have beenshown to cause an initial acidosis and hypokalemia. Treatment withhypertonic saline can also lead to a hyperchloremic acidosis, possiblydue to excessive chloride load. Some isotonic Ringers solutions andmildly hypertonic formulations mimic sodium and chloride concentrationratios found in plasma and are thought to decrease the likelihood ofacidosis. U.S. Pat. No. 3,993,750. Circulatory shock is often associatedwith an acidosis and, therefore, increased acidotic insult may bedeleterious.

Although hypertonic saline rapidly improves both blood pressure andcardiac output, these beneficial effects may be overshadowed bydeleterious effects from increased blood pressure. Uncontrolled internalbleeding in trauma patients may be aggravated by increased pressure,leading to increased bleeding. Return of normal blood pressure resultingin increased bleeding due to arterial pressure increase may lead toincreased mortality over no treatment. Therefore, ideal pre-hospitalresuscitation would increase cardiac output but only modestly increaseblood pressure.

Another aspect of resuscitation fluids is their use under less thanideal (non-hospital) conditions. Logistic restraints may severelycurtail transportation of weighty or voluminous material. In battlefieldsituations it may be impractical to administer large volumes, yet thereis a critical need to rapidly restore oxygen delivery to critical organsand to prevent or reverse the effects of traumatic shock.

SUMMARY OF THE INVENTION

Briefly, therefore, the present invention is directed to a resuscitationfluid comprising: an ionic salt at a concentration over about 0.9% byweight; at least one soluble protein; an intermediate energy substrate;and optionally an agent to mitigate intracellular acidosis.

The present invention is also directed to a method of preventing ortreating septic shock, hemorrhagic shock, hypotension, acidosis, and/orhypovolumia, the method comprising: administering to a subject in needof treatment or prevention of one or more of septic shock, hemorrhagicshock, hypotension, acidosis, and/or hypovolumia at least one ionicsalt, at least one soluble protein, and at least one intermediate energysubstrate.

The present invention is also directed to a method of making aresuscitation fluid, the method comprising intermixing at least oneionic salt, at least one soluble protein, and at least one intermediateenergy substrate.

The present invention is also directed to a resuscitation fluid preparedaccording to the method described above.

These and other aspects of the invention will be understood and becomeapparent upon review of the specification by those having ordinary skillin the art.

DETAILED DESCRIPTION OF SEVERAL EMBODIMENTS

Reference now will be made in detail to the embodiments of theinvention, one or more examples of which are set forth below. Eachexample is provided by way of explanation of the invention, notlimitation of the invention. In fact, it will be apparent to thoseskilled in the art that various modifications and variations can be madein the present invention without departing from the scope or spirit ofthe invention. For instance, features illustrated or described as partof one embodiment can be used on another embodiment to yield a stillfurther embodiment. Thus, it is intended that the present inventioncover such modifications and variations as come within the scope of theappended claims and their equivalents. Other objects, features andaspects of the present invention are disclosed in or are obvious fromthe following detailed description. It is to be understood by one ofordinary skill in the art that the present discussion is a descriptionof exemplary embodiments only, and is not intended as limiting thebroader aspects of the present invention.

The present invention makes a paradigm shift in the design and use ofresuscitative fluids. The present resuscitative fluid, discussed in moredetail below, is administered to a subject at an ionic strength that issignificantly higher than is physiologically normal with the result thatit causes transfer of the body's interstitial fluid from theinterstitial space into the vascular space to replenish vascular fluidvolume. However, the novel fluid is designed to mitigate or avoid theadverse consequences that would normally be expected to accompany suchtherapy. In addition to an ionic salt, which is present in a hypertonicconcentration, the novel fluid also includes an agent designed to helpmaintain normal aerobic cell metabolism, a soluble protein, at least oneintermediate energy substrate, and optionally, an agent to reduce oravoid the body's inflammatory response.

Consequently, the novel resuscitative fluid is administered to a subjectin need of such treatment at significantly lower volume than wouldnormally be required and with results that are superior to resultsnormally expected with the use of conventional resuscitative fluids.These results were unexpected due to the beneficial effect on cellmetabolism and minimization of inflammatory response that has beendemonstrated, while avoiding the adverse consequences one havingordinary skill in the art would expect to accompany the administrationof a hypertonic solution.

The ionic salt of the present fluid is preferably a pharmaceuticallyacceptable salt that ionizes to provide osmotic pressure in an aqueoussolution. Preferred salts include sodium chloride (NaCl) and potassiumchloride (KCl). NaCl is an especially preferred salt for use as theagent to augment intravascular fluid. In preferred embodiments, the saltis in the form of a saline solution. Those having ordinary skill in theart will recognize that saline is a solution of NaCl in sterile water,used commonly for intravenous infusion.

The concentration of the ionic salt in the present resuscitative fluidis sufficient to cause transfer of fluids from the interstitial space tothe vascular space in the body of the subject receiving the fluid. Theuse of the hypertonic solution causes replenishment of vascular fluidvolume by using the subject's own bodily fluids. The ability to utilizethe subject's own fluids for cell resuscitation allows treatment usingtower volumes of resuscitation fluid than utilized in traditionalmethods of treating and traditional resuscitation fluids.

Hypertonic saline is highly effective at restoring intravascular volumeat modest administered amounts. Hypertonic saline utilizes oncoticforces by the interstitial fluid to resuscitate a subject suffering fromshock. Typical hypertonic saline solutions have a concentration ofbetween about 3% and about 7.5%.

In some embodiments, the present resuscitation fluid contains betweenabout 0.9% to about 15% salt by weight of the total solution, morepreferably between about 5% to about 10% salt by weight of the totalsolution. An especially preferred concentration is about 7.5 wt %. Itmay be preferable to include the salt in the present fluid as a salinesolution having a concentration of between about 5% and 10%.

As previously discussed, the use of hypertonic saline alone oftenresults in an inflammatory response in the subject, as well as forcingcell metabolism into an anaerobic regime from which the cells are unableto recover.

The soluble protein component of the present resuscitation fluid actsalong with the ionic salt to increase the osmotic pressure in thevascular system of the subject. At least one soluble protein is includedin the novel fluid, but two or more types of protein can be used. Whenit is said that the protein is a “soluble protein”, it is meant that theprotein is soluble in the hypertonic salt solution of the present fluidat least at the concentration at which it is present in the fluid. Theprotein is preferably negatively charged, thereby increasing the shiftof the chemical potential across the cell membranes and improving themovement of the fluid from the interstitial space to the vascular space,as previously discussed.

The soluble protein is preferably an albumin. Those having ordinaryskill in the art will recognize that “albumin” refers generally to anyprotein with water solubility, which is moderately soluble inconcentrated salt solutions, and experiences heat coagulation.Substances containing albumin are called albuminoids. In an exemplaryembodiment, the preferred albumin is human serum albumin. Albumin isnegatively charged.

In normal mammalian physiology, albumin is necessary for maintaining theosmotic pressure needed for proper distribution of body fluids betweenthe intravascular compartments and body tissues. During episodes ofhemorrhagic and/or ischemia disorders, additional albumin may beadministered to increase the osmotic pressure as necessary to directflow of the body's own fluids from the interstitial space to thevascular space.

The soluble protein preferably has antioxidant activity. As used herein,the term “antioxidant activity” refers to substances that slow orprevent the oxidation of other chemicals. The antioxidant activity ofthe preferred soluble proteins may aid in minimizing reperfusion injury.

In exemplary embodiments, the present resuscitation fluid includesbetween about 15% and 40% by weight soluble protein, more preferablybetween about 20% and about 30% by weight soluble protein. An especiallypreferred concentration is about 25 wt %.

The intermediate energy substrate of the present resuscitation fluid isuseful to improve and/or maintain cell metabolism after the cells havebeen forced into an anaerobic metabolism regime. During periods ofhemorrhagic and/or ischemia disorders, the cells are often in ananaerobic environment. Even after oxygen flow is restored to the cells,they are often unable to revert back to aerobic metabolism andultimately die. The inability to successfully address this metabolicimbalance is a common problem with traditional resuscitation fluids andtreatments. The inventors have found that this problem can be overcomeby including a suitable intermediate energy substrate in theresuscitation fluid.

Exemplary intermediate energy substrates that are useful in the presentinvention include keto-acids and their carboxylate anions. Keto-acidsare organic acids containing a ketone functional group and a carboxylicacid group. Keto-acids are typically classified as alpha-keto acids,having the keto group adjacent to the carboxylic acid; beta-keto acids,having the ketone group at the second carbon from the carboxylic acid;or gamma-keto acids, having the ketone group at the third carbon fromthe carboxylic acid.

In an exemplary embodiment, the present intermediate energy substrate isone or more alpha-keto-acid and carboxylate anions thereof. Anespecially preferred intermediate energy substrate is pyruvate—thecarboxylate anion of pyruvic acid. The present intermediate energysubstrate is useful for helping cells continue ATP production and formaintaining energy and ionic gradients during periods of ischemia.

In exemplary embodiments, the present resuscitation fluid includesbetween about 0.1% and about 10% by weight intermediate energysubstrate, more preferably between about 0.5% and about 2% by weightintermediate energy substrate. An especially preferred concentration isabout 1 wt %.

Optionally, the present fluid contains an agent to reduce or avoid thebody's inflammatory response. Typically, this agent acts by aiding cellsto mitigate combat intracellular acidosis by scavenging free radicals.As used herein, the terms “agent to reduce or avoid the body'sinflammatory response” can be used interchangeably with the terms “agentto mitigate intracellular acidosis”.

Acidosis is an increased acidity (i.e., hydrogen ion concentration) ofblood plasma. Generally, acidosis is said to occur when arterial pHfalls below 7.35. During acidosis, there is an increase in theconcentration of free-radicals in the cell environment. An increase infree radicals triggers the body's inflammatory response, resulting ininflammation of the affected area. When the affected area is inflamed,the movement of fluids across the cell membranes is impeded. Byinclusion of one or more agents to mitigate intracellular acidosis, thefree radicals are scavenged, preventing inflammation. By preventinginflammation, the present resuscitation fluid demonstrates improvedrates of flow of fluid from the interstitial space to the vascularspace. Although hypertonic saline has been shown to have someanti-inflammatory properties, those properties are not sufficient tocombat the increase in free-radicals. Additional free-radical scavengingthat is provided by the agent to mitigate intracellular acidosisstrengthens the mitigation of cellular acidosis during cellularresuscitation and improves the outcome of the administration of theresuscitative fluid.

In exemplary embodiments, a preferred agent to mitigate intracellularacidosis is N-acetylcysteine. N-acetylcysteine is a free-radicalscavenger and is the N-acetyl derivative of the amino acid L-cysteine.In mammals, N-acetylcycteine is a precursor in the formation ofantioxidant glutathione in the body.

In exemplary embodiments, the present resuscitation fluid includesbetween about 0.2% and about 20% by weight of the one or more agents tomitigate intracellular acidosis, more preferably between about 0.5% andabout 4% by weight of the agent to mitigate intracellular acidosis. Anespecially preferred concentration is about 2 wt %.

The resuscitation fluid of the present invention preferably has a pH ofbetween about 6.5 and 7.0, more preferably between about 6.6 and 6.9,even more preferably between about 6.7 and 6.85. In especially preferredembodiments, the present resuscitation fluid has a pH of about 6.8.

In one embodiment, the present resuscitation fluid includes at least oneionic salt, albumin, N-acetylcysteine, and pyruvate. More specifically,in an exemplary embodiment, the present resuscitation fluid includesbetween about 5% and about 10% of an ionic salt (by weight), betweenabout 0.5% and about 4% N-acetylcysteine (by weight), between about 20%and about 30% albumin (by weight), and between about 0.5% and about 2%pyruvate (by weight).

In another embodiment, the present resuscitation fluid consistsessentially of at least one ionic salt, at least one soluble protein, atleast one intermediate energy substrate, and at least one agent tomitigate intracellular acidosis.

In yet another embodiment, the present resuscitation fluid consistsessentially of NaCl, N-acetylcysteine, albumin, pyruvate, and water.

In one embodiment, the present resuscitation fluid is substantially freeof sodium lactate, calcium chloride, and potassium chloride. In yetanother embodiment, the present resuscitation fluid is substantiallyfree of sodium lactate. In a different embodiment, the presentresuscitation fluid is substantially free of calcium chloride. In aneven different embodiment, the present resuscitation fluid issubstantially free of potassium chloride. In at least one embodiment,the present resuscitation fluid is substantially free of Ringer'ssolution or lactated Ringer's solution.

Without being bound to this or any other theory, the inventors believethat the present resuscitation fluid provides resuscitation on acellular level; by increasing the flow of the body's own fluid from theinterstitial space to the vascular space. Traditional resuscitationfluids are unable to achieve this result. Ringer's solution (and similarresuscitation fluids) do not have the osmolarity necessary to mobilizethe subject's own fluids. For this reason, larger volumes of fluid arenecessary to successfully treat the subject.

Hypertonic saline, alone, results in inflammation of the cell membranes,thereby reducing the flow of fluid from the interstitial space to thevascular space. The present fluid overcomes these problems, aspreviously discussed, by mitigating the deleterious effects ofhypertonic saline, while taking advantage of the beneficial effectsprovided by the high ionic strength.

In another aspect, the invention is a method of making a resuscitationfluid. The method includes intermixing at least one ionic salt, at leastone soluble protein, and at least one intermediate energy substratecomponent. The method optionally includes intermixing at least onecomponent to mitigate intracellular acidosis.

The intermixing step may be conducted at temperatures below roomtemperature, at temperatures above room temperature, and/or at atemperature of about room temperature. In some embodiments, it may bedesirable to utilize different temperatures at different stages of theintermixing step.

Additionally, the intermixing step may be conducted by one or more ofstirring, agitation, heating, and cooling. In some embodiments, it maybe desirable to utilize more than one method of intermixing at differentstages of the intermixing step.

In some embodiments, the intermixing step may be conducted in a carriersolution, such as those carrier solutions described above. It may bedesirable to mix one or more of the components of the resuscitationfluid into a carrier solution individually before combining thecomponents. In additional embodiments, the components may be added tothe carrier solution sequentially. In other embodiments, the componentsmay be added to the carrier solution simultaneously, or substantiallysimultaneously.

It may be desirable to add the components sequentially and slowly to acarrier solution, while maintaining a pH level at or about physiologicallevels. For example, it may be desirable to add one or more componentsin a fractional manner, adjusting the pH between additions as needed.

The resuscitation fluid may be supplied in the form of a noveltherapeutic composition that is believed to be within the scope of thepresent invention. The relative amounts of each component in thetherapeutic composition may be varied, and may be as described above.The resuscitation fluid may be provided in the therapeutic compositionso that the preferred amounts of each of the components are supplied bya single dosage form.

When the present combination is supplied along with a pharmaceuticallyacceptable carrier, a pharmaceutical composition is formed. Apharmaceutical composition of the present invention is directed to acomposition suitable for the treatment and/or prevention of one or moreof septic shock, hemorrhagic shock, hypotension, acidosis, andhypovolumia. Pharmaceutically acceptable carriers include carriersolutions such as water, saline, phosphate solution or buffer, bufferedsaline, and other carriers known in the art. Pharmaceutical compositionsmay also include stabilizers, anti-oxidants, colorants, anti-microbialagents, bacteriostats, and diluents. Pharmaceutically acceptablecarriers and additives are chosen such that side effects from thepharmaceutical composition are minimized and the performance of thecomposition is not canceled or inhibited to such an extent thattreatment is ineffective.

The term “pharmaceutically effective amount” shall mean that amount of adrug of pharmaceutical agent that will elicit the biological or medicalresponse of a tissue, system, animal, or human that is being sought by aresearcher or clinician. This amount can be a therapeutically effectiveamount.

The term “pharmaceutically acceptable” is used herein to mean that themodified noun is appropriate for use in a pharmaceutical product.Pharmaceutically acceptable cations include metallic ions and organicions. More preferred metallic ions include, but are not limited to,appropriate alkali metal salts, alkaline earth metal salts, and otherphysiological acceptable metal ions. Exemplary ions include aluminum,calcium, lithium, magnesium, potassium, sodium, and zinc in their usualvalences. Preferred organic ions include protonated quaternary ammoniumcations, including in part, trimethylamine, diethylamine,N,N′-dibenzylethylenediamine, chloroprocaine, choline, diethanolamine,ethylenediamine, meglumine (N-methylglucamine), and procaine. Exemplarypharmaceutically acceptable acids include without limitation,hydrochloric acid, hydrolodic acid, hyrobromic acid, phosphoric acid,sulfuric acid, methanesulfonic acid, acetic acid, formic acid, tartaricacid, maleic acid, malic acid, citric acid, isocitric acid, succinicacid, lactic acid, gluconic acid, glucuronic acid, pyruvic acid,oxalacetic acid, fumaric acid, propionic acid, aspartic acid, glutamicacid, benzoic acid, and the like.

In another aspect, the invention is a method of preventing or treatingseptic shock, hemorrhagic shock, hypotension, acidosis, and/orhypovolumia. The method preferably includes administering to a subjectin need of treatment or prevention of one or more of septic shock,hemorrhagic shock, hypotension, acidosis, and/or hypovolumia at leastone ionic salt, at least one soluble protein, and at least oneintermediate energy substrate component. The method optionally includesadministering at least one component to mitigate intracellular acidosis.These components can be administered in the form of a resuscitativefluid.

In the present method, a subject in need of prevention or treatment ofshock-related conditions is treated with the previously describedresuscitation fluid, wherein the fluid is administered in a dosage oreffective amount that is sufficient to constitute a treatment orprevention of shock-related conditions.

As used herein, an “effective amount” means the dose to be administeredto a subject and the frequency of administration to the subject which isreadily determined by one of ordinary skill in the art, by the use ofknown techniques and by observing results obtained under analogouscircumstances. In determining the effective amount or dose, a number offactors are considered by the attending diagnostician, including, butnot limited to, the potency and duration of action of the compoundsused; the nature and severity of the condition to be treated as well ason the sex, age, weight, general health, and individual responsivenessof the patient to be treated, and other relevant circumstances.

The phrase “therapeutically-effective” indicates the capability of anagent to prevent, or improve the severity of, the condition, whileavoiding adverse side effects typically associated with alternativetherapies.

In the present method, the amount of the ionic salt to be used in thenovel treatment preferably ranges from about 0.9% to about 15% by weightof the total fluid, the amount of the soluble protein is preferablybetween about 15% and about 40% by weight of the total composition, andthe amount of the intermediate energy substrate is preferably betweenabout 0.1% and about 10% by weight of the total composition. In someembodiments, the novel treatment may further include an amount ofbetween about 0.2% and about 20% by weight of the total composition ofat least one agent to help cells combat intracellular acidosis.

In some embodiments, the amount of resuscitation fluid administeredaccording to the present method is between about 5% to about 100% theamount of blood loss, more preferably between about ⅛th and ¼th thetotal blood loss. Stated differently, for a one liter hemorrhage, theamount of the present resuscitation fluid administered according to thepresent method would be between about 50 mL to about 1000 mL, morepreferably between about 125 mL and about 250 mL.

The amount of novel resuscitation fluid that is used in the subjectmethod may be an amount that, when administered, is sufficient toconstitute the prevention or treatment of shock-related conditions. Theamount of resuscitation fluid utilized in the present method may varydepending on the severity and/or imminence of the particularshock-related condition in a particular subject.

Dosages can vary within wide limits and will be adjusted to theindividual requirements in each particular case. In general, foradministration to adults, an appropriate dosage has been describedabove, although the limits that were identified as being preferred maybe exceeded if expedient.

As used herein, the terms “treating” or “to treat” mean to alleviatesymptoms, eliminate the causation either on a temporary or permanentbasis, or to prevent or slow the appearance of symptoms. The term“treatment” includes alleviation, elimination of causation of orprevention of the conditions described above. Besides being useful forhuman treatment, the present composition and method are also useful fortreatment of mammals, including horses, dogs, cats, rats, mice, sheep,pigs, etc.

The term “subject” for purposes of treatment or prevention includes anyhuman or animal subject who is in need of the prevention of, ortreatment for, the above conditions. The subject is typically a humansubject.

For methods of prevention, the subject is any human or animal subject,and preferably is a subject that is in need of prevention and/ortreatment of the above shock-related conditions. The subject may be ahuman subject who is at risk for shock, and related conditions, such asthose described above. The subject may be at risk due to injury,bleeding, infection, emotional distress, and other known precursors forshock.

The phrases “combination therapy,” “co-administration,” “administrationwith,” or “co-therapy,” in defining the use of the present resuscitationfluid and present method of administering the present resuscitationfluid are intended to embrace administration of each component in asequential manner in a regime that will provide beneficial effects ofthe drug combination, and is intended as well to embraceco-administration of these components in a substantially simultaneousmanner, such as in a single dosage device having a fixed ratio of theseactive agents, or in multiple, separate dosage devices for each agent,where the separate dosage devices can be administered togethercontemporaneously, or administered within a period of time sufficient toreceive a beneficial effect from each of the constituent agents of thecombination.

The phrases “therapeutically effective” and “effective for thetreatment, prevention, or inhibition,” are intended to qualify theamount of each component for use in the combination therapy which willachieve the goal of prevention of, or treatment for, shock-relatedconditions over treatment of each component by itself, while avoidingadverse side effects typically associated with alternative therapies.

Although the combination of the present invention may includeadministration of each component within an effective time of eachrespective component, it is preferably to administer each of therespective components contemporaneously, and more preferable toadminister the respective components in a single delivery dose.

The present method includes one or more of intravenous, topical, andoral administration. In some embodiments, the components may be admixedbefore administration. It may be preferred to admix at least two of thecomponents before administration, with the remaining component orcomponents being administered individually to the subject. In anotherembodiment, each of the components may be administered individually tothe subject.

In yet another embodiment, at least one component may be intermixed witha carrier solution, for example, water, before administration to thesubject. In some embodiments, it may be desirable to intermix all of thecomponents with a carrier solution before administration to the subject.

The present resuscitation fluid may also be used as a storage solutionfor organs during organ transplant, for wound irrigation, as a solutionfor urological and gynecological procedures, to treat intracranialhypertension from head injury, and to help reduce contrast inducednephrotoxicity. Pre-hospital uses for the present resuscitation fluidinclude ambulance use, battlefield use, emergency room use, trauma, andintensive care use. Similarly, the present resuscitation fluid may beutilized for veterinary use in the same manner it is utilized from humanuse.

The present resuscitation fluid may be particularly advantageous for usein battlefield, field hospital, and/or ambulatory environments. Priorart resuscitation fluids typically required a dosage rate of about 3times the amount of blood loss. Stated differently, for every liter ofblood loss, a typical prior art resuscitation fluid treatment required 3liters of resuscitation fluid. As stated above, the presentresuscitation fluid is intended to be typically used in dosages lessthan the total amount of blood loss. Accordingly, the storage andtransport of the present resuscitation fluid provides advantages overthe prior art resuscitation fluids due to this dosage reduction.

Moreover, in some embodiments, the present resuscitation fluid may bedried, for example by freeze drying or spray drying, to a powder andstored in the powder form. The powdered form of the resuscitation fluidcan then be reconstituted with sterile water, saline, or other carrierfluids at the time of administration. The reconstituted resuscitationfluid of the present invention is clear, non-cloudy, stable and readyfor use. This ability to store the resuscitation fluid as a powder aidsin the shipping and supplying of the resuscitation fluid for use inremote locations, such as battlefields, field hospitals, and third-worldcountries.

The following examples describe preferred embodiments of the invention.Other embodiments within the scope of the claims herein will be apparentto one skilled in the art from consideration of the specification orpractice of the invention as disclosed herein. It is intended that thespecification, together with the examples, be considered to be exemplaryonly, with the scope and spirit of the invention being indicated by theclaims which follow the examples. In the examples all percentages aregiven on a weight basis unless otherwise indicated.

Example 1

This example illustrates a method of forming an embodiment of thepresent resuscitation fluid.

To form a 100 mL solution, add to pyrogen free distilled water 7.5 gNaCl (Fisher), 25 g albumin bovine serum (Sigma Aldrich cGMP, ≧98.5%,non-animal source), 2 g N-acetyl cysteine (Sigma, Fraction V, ≧96% heatshock fractionate, remainder mostly globulins), and 1 mL pyruvate (FlukyChemika, >97% by GC).

Example 2

This example illustrates an additional method of forming an embodimentof the present resuscitation fluid.

50 mL of pyrogen free distilled water were added to a flask on a stirplate. While stirring, 7.5 g NaCl and 2 g N-acetyl cysteine were addedto the flask. The pH was adjusted to 7.4 using 1N NaOH that was sterilefiltered (0.2 micron). 1 mL pyruvate was added. After 15 minutes, the pHwas adjusted to 7.4 using 1N NaOH. 20 mL water were added to the flask,followed by the addition of 10 g albumin. The composition was stirreduntil the albumin was dissolved, then the pH was adjusted to 7.0. Anadditional 5 g of albumin was added and allowed to dissolve before thepH was adjusted to 7.0. An additional 10 g of albumin was then added andallowed to dissolve while stirring, followed by addition of water to atotal volume of 100 mL. The final pH of the fluid was 6.8.

Example 3

This example relates to a rat test, wherein a rat was allowed tohemorrhage without treatment. A 410 g male Sprague Dawley rat wasanesthetized with 0.24 mL of 50 mg/mL ketamine, 0.07 mL of 20 mg/mLxylazine, and 0.05 mL of 10 mg/mL acepromazine. The following resultswere observed:

Time (s) Action MAP (mm Hg) Notes 1130 Catheters in place 90 1130   4 cchemorrhage 50 Initial bleed 1135 1.5 cc hemorrhage 40 Rebleed 1150 1.0cc hemorrhage 37 Rebleed 1225 1.0 cc hemorrhage 45 1227 1.0 cchemorrhage 40 1235 death

Example 4

In Example 4, a rat suffering from hemorrhagic shock was treated withthe present resuscitation fluid. A 405 g male Sprague Dawley rate wasanesthetized with 0.24 mL of 50 mg/mL ketamine, 0.07 mL of 20 mg/mLxylazine, and 0.05 mL of 10 mg/mL acepromazine. After hemorrhage wasinduced, the following results were observed:

Time (s) Action MAP (mm Hg) Notes 1423 Catheters in place 100 1423 4 cchemorrhage 35 Initial bleed 1430 1 cc hemorrhage 40 Rebleed 1436 0.5 cchemorrhage   Rebleed 1445 2 cc hemorrhage 33 Rebleed 1450 0.2 cchemorrhage   36 Rebleed 1521 1 cc resuscitation fluid 90 Rat waking up(Example 2) 1525 Redose anesthesia 90 1536 No action 75 Anesthesiaeffective 1553 1 cc resuscitation fluid 68 Rat waking up (Example 2)1554 No action 79 1556 No action 91 1600 No action 93 1615 No action 801630 sacrifice

As can be seen from the above data, a rat treated with a small dosage ofthe present resuscitation fluid (prepared according to the procedure ofExample 2) may be successfully resuscitated after significanthemorrhage.

The overall purpose of the experiments in animals is to establishsafety, appropriate dosage range, and efficacy prior to evaluation inhumans at risk for, or suffering from, shock-related conditions. Sincethe ultimate purpose of the present compositions and methods is toprovide a safe preparation that can be used to treat humans who mightnot be receiving effective treatment for shock-related conditions, thedosages in the animal studies are modeled after expected dosages forhuman treatment. Those having ordinary skill in the art will recognizethat small animal studies are typically conducted to determine safety,dosage and efficacy prior to treatment in humans. Similarly, thosehaving ordinary skill in the art will recognize that the correlation ofrat data to human treatment in this art is well-understood and accepted.

All references cited in this specification, including withoutlimitation, all papers, publications, patents, patent applications,presentations, texts, reports, manuscripts, brochures, books, internetpostings, journal articles, periodicals, and the like, are herebyincorporated by reference into this specification in their entireties.

The discussion of the references herein is intended merely to summarizethe assertions made by their authors and no admission is made that anyreference constitutes prior art. Applicants reserve the right tochallenge the accuracy and pertinency of the cited references.

Although preferred embodiments of the invention have been describedusing specific terms, devices, and methods, such description is forillustrative purposes only. The words used are words of descriptionrather than of limitation. It is to be understood that changes andvariations may be made by those of ordinary skill in the art withoutdeparting from the spirit or the scope of the present invention, whichis set forth in the following claims. In addition, it should beunderstood that aspects of the various embodiments may be interchangedboth in whole or in part.

1-41. (canceled)
 42. A resuscitation fluid for treating hypovolemia in asubject, wherein the resuscitation fluid is a solution comprising: anionic salt at a salt concentration between about 0.9% and about 15% byweight of the resuscitation fluid; a soluble protein at a proteinconcentration between about 15% and about 40% by weight of theresuscitation fluid; an intermediate energy substrate at an energysubstrate concentration between about 0.1% and about 10% by weight ofthe resuscitation fluid; and water.
 43. The resuscitation fluidaccording to claim 42 further comprising a buffer.
 44. The resuscitationfluid according to claim 43, wherein the resuscitation fluid has a pHadjusted by the buffer to be between about 6.5 and about 7.0.
 45. Theresuscitation fluid according to claim 42, wherein the ionic salt has asalt concentration between about 5% and about 10% by weight of theresuscitation fluid.
 46. The resuscitation fluid according to claim 42,wherein the protein concentration is between about 20% and about 30% byweight of the resuscitation fluid.
 47. The resuscitation fluid accordingto claim 42, wherein the energy substrate concentration is between about0.5% and about 2% by weight of the resuscitation fluid.
 48. Theresuscitation fluid according to claim 42 further comprising an agent tomitigate intracellular acidosis.
 49. The resuscitation fluid accordingto claim 48, wherein the agent to mitigate intracellular acidosis ispresent in the resuscitation fluid at an agent concentration betweenabout 0.2% and about 20% by weight of the resuscitation fluid.
 50. Theresuscitation fluid according to claim 48, wherein the agentconcentration is between about 0.5% and about 4% by weight of theresuscitation fluid.
 51. The resuscitation fluid according to claim 48,wherein the agent to mitigate intracellular acidosis isN-acetylcysteine.
 52. The resuscitation fluid according to claim 42,wherein the soluble protein comprises albumin.
 53. The resuscitationfluid according to claim 52, wherein the soluble protein comprises humanserum albumin.
 54. The resuscitation fluid according to claim 42,wherein the intermediate energy substrate comprises a keto-acidcontaining a ketone functional group and a carboxylic acid group. 55.The resuscitation fluid according to claim 42, wherein the intermediateenergy substrate comprises a carboxylate anion of a keto-acid containinga ketone functional group and a carboxylic acid group.
 56. Theresuscitation fluid according to claim 42, wherein the intermediateenergy substrate comprises pyruvate.
 57. The resuscitation fluidaccording to claim 42, wherein the ionic salt comprises sodium chloride.58. A resuscitation fluid for treating hypovolemia in a subject, whereinthe resuscitation fluid is a solution comprising; an ionic salt; asoluble protein, wherein the soluble protein comprises albumin; anintermediate energy substrate, wherein the intermediate energy substratecomprises pyruvate; an agent to mitigate intracellular acidosis, whereinthe agent to mitigate intracellular acidosis comprises N-acetylcysteine;and water
 59. The resuscitation fluid according to claim 58 furthercomprising a buffer, wherein the resuscitation fluid has a pH adjustedby the buffer to be between about 6.5 and about 7.0.
 60. Theresuscitation fluid according to claim 58, wherein the resuscitationfluid comprises the ionic salt between about 0.9% and about 15% byweight; albumin between about 15% and about 40% by weight; pyruvatebetween about 0.1% and about 10% by weight; and N-acetylcysteine betweenabout 0.2% and about 20% by weight.